Pediatric In-Toeing

(aka "Pigeon Toed")

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Is my Child Pigeon Toed?  What is Pediatric In-Toeing?

In-toeing is a condition where the toes point inward when a child walks (instead of pointing forward). It is commonly called "Pigeon-Toed", and it is one of the most common reasons for parents to bring their child to a pediatric orthopedist.  

Before going forward, its important to emphasize that most cases are part of normal child development and will resolve on their own.  The average infant has 5 degrees of internal rotation (in-toeing) which gradually moves into the normal adult alignment of 10 degrees external rotation (out-toeing) by 8 years old.  So the majority of infants have a little internal rotation and some infants have a little extra (in the same way that all babies are different heights and weights).  Most of what parents notice is within the spectrum of "normal" or "physiologically acceptable" rotation.  However, there are rare cases of abnormal rotation that require further investigation.  

Diagnosing In-Toeing in Kids:

The In-toeing (internal rotation of the leg) is typically seen by parents once the child beings walking (most commonly noticed between the ages of 1-3 years old).  Its usually seen in both legs.  Parents may notice that the child is falling or tripping more frequently but its otherwise asymptomatic to the child.  

The first step in diagnosis is for the doctor to simply watch the child walking and to look at the angle of the foot relative to a straight line (called foot progression angle).  Sometimes this alone can be a challenge because young children cant walk in a straight line, or follow directions, so doctors usually take the kids out into the office hallway and have them walk or run up and down the hallway a few times.

 If there is increased internal rotation and in-toeing identified, the legs are examined to determine the cause.  In-toeing can be caused by increased internal rotation at different points along the leg: 1) it can occur at the hip, called increased hip anteverision (the hip is pointed slightly forward), or 2) it can occur at the mid-leg (called internal tibial torsion, most common), or 3) it can occur in the foot, called metatarsus adductus (read here).  There are a few tests doctors can perform in the office to identify where the internal rotation is coming from.

Doctors test hip anteversion by comparing the degree of hip internal and external rotation.  If there is a significant imbalance, then excess anteversion is suspected, and x-rays of the hip and pelvis are ordered to pursue this further, looking specifically for developmental dysplasia of the hip (see talk).  

The degree of tibial torsion can be measured by having a child lie on their belly and measuring the alignment between the thigh and the foot (called the thigh-foot angle).  Most kids have about 5 degrees of internal rotation, and anything beyond 10 degrees is considered to be in-toeing.  

Foot rotation is evaluated by comparing the heel of the foot to the front of the foot.  If there is a significant curvature of the foot, metataruss adductus is suspected. 

Once the site of in-toeing is identified, it is rare that doctors need to order further testing, because as you will read below, treatment is rarely necessary.  However, kids will occasionally report symptoms that make doctors want to order some extra tests to rule out other underlying conditions.  These symptoms include painful in-toeing, progressively worsening in-toeing, severe in-toeing (more than 2 standard deviations outside of normal), a difference in leg lengths, and lastly a family history of metabolic conditions (like rickets).

Treating In-Toeing:

The best part about pediatric In-Toeing is that the vast majority of these cases get better on their own by the time a kid reaches their 6th birthday.  Braces or shoe orthotics have not been shown to speed up, or change the natural progression of in-toeing.

Rare cases of significant in-toeing that persists into adolescence may require surgery on the affected leg to re-align the rotation to improve walking and coordination.  

Outcomes:  

Most kids do great because its an issue that resolves with growth.  Parents just need some reassurance.  

References

1) Lincoln TL, Suen PW. Common rotational variations in children. JAAOS 2003 11: 312-20. full article.

2) Wenger DR et al. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. JBJS 1989; 71: 800-810. full article.

3) Staheli LT. Rotational problems in children. JBJS 1993; 75: 939-949. full article. normal toddler anatomy.